Get CA DE 2501F 2003
2501F (12-03) (INTERNET) Page 1 of 4 CU CARE RECIPIENT’S AUTHORIZATION FOR DISCLOSURE OF PERSONAL-HEALTH INFORMATION I authorize my physician or practitioner, as identified on Part D of this claim, to disclose my current personal-health information to my care provider, as identified on Part A of this claim, and to the California Employment Development Department (EDD). I understand that such information includes a diagnosis and prognosis of my current condition, the date it commenced, and .
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